Indocyanine Green-Guided Intraoperative Imaging to Facilitate Video-Assisted Retroperitoneal Debridement for Treating Acute Necrotizing Pancreatitis

This protocol presents indocyanine green-guided video-assisted retroperitoneal debridement for treating severe acute necrotizing pancreatitis. The ICG-guided VARD is an easy and feasible approach to visualize the well perfused adjacent normal tissues and vascular structure of mesenteric vessels. Begin by inserting a 12 millimeter laparoscopic trocar along the dilated tract to the retroperitoneal necrotic collections.

Apply carbon dioxide pneumoretroperitoneum if a wider debridement space is needed by insufflating carbon dioxide through the 12 millimeter trocar. Then place a near infrared fluorescence laparoscopic via the observing trocar and make an additional 10 millimeter incision subcostal in the left or right flank at the mid-axillary line as described in the text manuscript. Insert the 10 millimeter operative trocar and switch the display mode of the laparoscopic to multi-display mode Before separating necrotic debris from adjacent normal tissue.

Inject the first bolus of indocyanine green or ICG intravenously in a peripheral vein, then flush with 10 milliliters of saline. After 10 to 20 seconds, visualize peak perfusion of adjacent normal tissues or vessels in the fluorescence field. A more distinct separating surface will be distinguishable from the debris.

Remove the poorly perfused and loosely adherent necrotic debris using laparoscopic graspers. Avoid tearing the underlying bowel or vessel. Inject another bolus of ICG intravenously if ICG fluorescence decay.

After removing the bulk of necrotic debris, irrigate the cavity of the retroperitoneum with saline and aspirate with a laparoscopic aspirator until the lavage fluid becomes clear. Place at least one pair of drainage tubes in the deepest region of the cavity after debridement before proceeding with the fascia and skin suturing. The 41-year-old male patient suffered from moderately acute necrotizing pancreatitis and received the ICG-guided VARD.

Abdominal contrast enhanced CT scan revealed that the necrotic collections consist of the lesser arc peripancreatic space and extended to the bilateral retroperitoneum. Infected necrosis in the right retroperitoneum was persistent after initial percutaneous drainage and the first VARD was performed about four weeks after the onset of pancreatitis. The ICG perfusion of adjacent normal tissues or vessels was visualized in the fluorescence field and a clearer separating surface was distinguished from the debris.

Infected necrosis was resolved and drainage tubes were removed seven days after ICG-guided VARD. ICG-guided VARD warrants further randomized clinical trials to confirm its practicability and safely treating acute necrotizing pancreatitis.